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    Exam Review

    1. A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?
      A)Instruct the parents to avoid bringing fresh flowers into the room.
      B)Use an N95 respirator.
      C)Initiate contact precautions.
      D)Place the child in a room that has a HEPA filtration system.
    2. A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
      A)"You should use patterned-paced breathing when changing positions."
      B)"You should change positions as little as possible."
      C)“You can splint the incision with a pillow when changing positions.”
      D)"You can apply counterpressure to your back with each position change."
    3. A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?
      A)"I will eat turkey sausage for breakfast."
      B)"I will put ketchup on my hot dogs."
      C)"I will use frozen vegetables rather than canned."
      D)"I like to use store-bought spaghetti sauce."
    4. A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
      A)Anaphylactic
      B)Acute hemolytic
      C)Febrile
      D)Circulatory overload
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    Exam Review

    1. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
      A)Cover the wound with sterile, saline-soaked gauze.
      B)Hold gentle, direct pressure on the protruding organ.
      C)Place the client's knees in an extended position.
      D)Raise the head of the bed to a 45° angle.
    2. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
      A)Inject 15 units of air into the regular insulin vial.
      B)Place the cap over the needle.
      C)Verify the dosage with another nurse.
      D)Withdraw 10 units of NPH insulin.
    3. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?
      A)"I'll take him back to the nursery, so you can get some rest."
      B)"If I turn him on his side, maybe he'll go back to sleep."
      C)"Babies need to cry soon after they are born to develop their lungs."
      D)"Let me show you how to swaddle and cuddle him, then you try."
    4. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?
      A)Limit the number of choices for the client.
      B)Use written signs to assist the client with locating the bathroom.
      C)Provide a stimulating environment for the client.
      D)Use confrontation to manage the client’s behavior.
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    Exam Review

    1. A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?
      A)"We will frequently check the top of his ears for sores."
      B)"We can turn the oxygen up to 10 when he has trouble breathing."
      C)"We can use petroleum jelly to keep his nares moist."
      D)"We will need to remove the nasal cannula when he is eating."
    2. A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?
      A)Denial
      B)Sublimation
      C)Regression
      D)Repression
    3. A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?
      A)"It is for clients who have a terminal illness."
      B)"It is for clients who are given 6 months or less to live."
      C)"It includes restriction of nutritional support."
      D)"It enhances quality of life by promoting comfort."
    4. A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include?
      A)Exercise when insulin is at its peak action.
      B)Eat a piece of fruit before exercising.
      C)Inject additional insulin before exercising.
      D)Avoid protein before exercising.
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    Exam Review

    1. A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)(SATA)
      A)Pale-colored toes
      B)Decreased skin turgor
      C)Pain relieved by analgesia
      D)Diminished capillary refill
      E)Sensation of tingling
    2. A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
      A)"I will carry my baby to the nursery."
      B)"I will have an identification band that matches the one my baby wears."
      C)"I can remove my security band to give to a family member."
      D)"I can take my baby to the lobby to visit family."
    3. A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?
      A)Physical therapist
      B)Primary care provider
      C)Occupational therapist
      D)Social worker
    4. A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?
      A)Dry hands thoroughly from fingers to wrist.
      B)Hold the hands slightly higher than the elbows when using running water.
      C)Wash hands under running water for at least 10 seconds.
      D)Clean hands with alcohol-based hand gel for 16 seconds.
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    Exam Review

    1. A nurse is collecting data from a 9-year-old child during a well-child visit. Which of the following findings should the nurse expect?
      A)Expresses conflict over independence and control
      B)Demonstrates self-centered thinking
      C)Displays emotional detachment from parents
      D)Grasps concept of cause-and-effect
    2. A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?
      A)Nursing care plan
      B)Controlled substance inventory record
      C)Incident report
      D)Provider's progress notes
    3. A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
      A)Turn on overhead lights briefly when checking IV lines.
      B)Open curtains between clients in semiprivate rooms.
      C)Wear shoes with rubber soles.
      D)Conduct change-of-shift report near the clients' rooms.
    4. A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?
      A)Encourage the toddler to flush the toilet while still seated.
      B)Have the toddler remain on the toilet for a minimum of 20 min.
      C)Wake the toddler every 2 hr. in the night to prevent bed-wetting.
      D)Give the toddler a sticker after each successful toileting attempt.
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    Exam Review

    1. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new prescription for propranolol. The nurse should plan to monitor the client for which of the following adverse effects of the medication?
      A)Ringing in the ears
      B)Bradycardia
      C)Hypertension
      D)Headache
    2. A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?
      A)The telephone numbers of the clients
      B)The room numbers of the clients
      C)The diagnoses of the clients
      D)The names of the clients' nearest relatives
    3. A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?
      A)Pain in the right upper abdomen
      B)Discomfort with urination
      C)Pain radiating to the jaw
      D)Increased abdominal discomfort prior to meals
    4. A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?
      A)Verify the amount of TPN solution the client is receiving every 4 hr.
      B)Place the client in Sims' position for catheter insertion
      C)Use clean technique when changing the catheter dressing
      D)Prepare the client for a chest x-ray to verify catheter placement
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